Trauma: Piecing The Puzzle Together

In December 2020, I presented a webinar within the Health and Patient Advocate community about working with complex mental health clients. What sparked the webinar's immediacy was that many of us have seen a dramatic increase in clients struggling with behavioral health issues either as a primary problem or a complicating factor to their medical diagnoses. Now that we are a full year into COVID-19, it is clear that the pandemic has exacerbated this already convoluted issue. Stress associated with living in a world of COVID-19 has been a contributing factor. Additionally, those who have contracted the disease, and especially those who had a more severe form of it, are dealing with the medical after-effects and psychological ones, including sometimes PTSD or even psychosis.

Why does trauma matter at the individual level?

My primary focus associated with trauma is the role it may play in my clients' behavioral health and medical diagnoses derived from traumatic events that occurred during their childhood and adolescence, as well as possibly before and even during birth. “ Behavioral health” is a term that has been defined by the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the US Department of Health and Human Services, as “… the promotion of mental health, resilience and wellbeing; the treatment of mental and substance use disorders; and the support of those who experience and/or are in recovery from these conditions, along with their families and communities.” It is an overarching term reflecting the complexity and interaction of these factors.

After working with clients struggling to find the proper care for extended periods of time before working with me, I often find the role of trauma has been overlooked. Their years' worth of misdiagnosis or treatments had been ineffective because their providers were not trained to be «trauma-informed.» This training has become increasingly relevant and something which I believe would be beneficial for all primary care providers and behavioral health professionals.

It turns out that:

1. Trauma can have a big impact at any age, but especially trauma that occurs during developmental years can have a life-long impact.

2. How each individual experiences a given traumatic experience will vary significantly due to that individual's ability to respond, adapt and cope, a function of resilience.

3. Trauma is also a function of the impact on the individual and the bigger systemic impact on a group.

One of the most interesting discoveries associated with trauma, especially childhood trauma, is its impact on an individual's long-term health. A longitudinal study on 17,000 individuals in the United States conducted during the late 1990s by the CDC and Kaiser Permanente called the Adverse Childhood Experience Study (ACES), examined the impact of childhood traumatic experience over time on their long term health as adults, including their:

• Behavioral health
• Decreases life expectancy
• Increases healthcare costs
• Reduces the ability to succeed in life roles such as school and work.

Further studies conducted triggered by the findings from ACES found that trauma impacts the development of major organ systems in the body and can be linked to later development of diseases of these major organ systems including:

• Heart disease
• Kidney disease
• Diabetes
• Auto-immune disorders
• Etc.

Moreover, stress during a birthmother's pregnancy can affect a developing fetus. The pregnant woman's elevated cortisol hormone level is passed through the placenta to the fetus. This elevates the stress of the fetus and negatively impacts its physical and emotional development, resulting in medical and behavioral consequences throughout its entire life.

ACES' shocking conclusions support that this is not just one person's issue; it is a public health crisis. In November 2019, NPR reported the CDC’s response to the study indicating «we can do more to prevent [this crisis].»

• Approximately 60% of the United States population at that time experienced at least one traumatic event during childhood.
• Close to 16% experienced four or more different types of traumatic events.
• The risk of experiencing traumatic events during childhood is significantly higher among women, American Indians, Alaskan Natives, and African Americans.
• The more types of traumatic events experienced, the more likely that person is to experience «negative outcomes» that will impact that individual for life.

Extending their analysis, the CDC showed that preventing childhood trauma just based on their study data "...could prevent 1.9 million cases of heart disease, the leading killer in this country. Similarly, it could prevent 2.5 million cases of obesity...and 21 million cases of depression." They further go on to link childhood trauma to «social well-being» and life accomplishments associated with school and jobs, highlighting that preventing the ACEs identified during the study «could have kept 1.5 million students from dropping out of [high] school.»

Trauma affects generations over time

As I briefly mentioned before, some segments of our country's population are at greater risk of experiencing Adverse Childhood Events. These include women, American Indians, Alaskan Natives, African Americans, and, although not mentioned by the CDC, those perceived as or self-declared as LGBTQIA, Asian Americans, and members of the Jewish and Muslim faiths. All of them have been victims of hate crimes and discrimination.

Systemic experience of trauma impacts a given segment of the population over time. For example, repeated hostile behaviors directed against a group marginalizes them. Without much prompting, we can think of the many atrocities perpetuated in our country against the groups I have listed. Demeaning and discriminatory acts traumatize these groups and make them feel like outsiders of lower worth and value, impacting their culture, identity — how they perceive themselves within society at large — and their resilience as individuals. This happens at the cellular developmental level over time and gets passed from one generation to the next.

Black Americans have historically been subjected to medical experiments without their knowledge, which has contributed to a deep cultural distrust, passing down generations of trauma that affect a segment of our population. Added to this has been a history of discriminatory treatment with our medical system. Black patients have been subject to racist and discriminatory treatment by practitioners leading to distrust and reduced access to resources, all of which could and should have been prevented. This has had an unfortunate impact on our Black population in America beyond just access to care. For example, there is a deep-seated distrust of the white medical system regarding the COVID-19 vaccine by a population that is especially vulnerable to the disease. Right now, several prominent Black figures, including popular Black athletes and Vice President Kamala Harris, are actively encouraging members of the Black community to get vaccinated for their health and safety. This is an example of how systemic trauma can impact a population over time, and the Black population is not the only minority subjected to this in our society.

Working with a provider trained in Trauma-Informed Care

These are just a few examples of how trauma can impact an individual and segments of our population, making it an essential factor in someone's health history to piece together the puzzle. Working with a qualified provider, someone trained in Trauma-Informed Care (TIC), means that the provider is able to understand the impact trauma may have on an individual and is sensitive to the appropriate treatment options.

A provider with a TIC practice is able to acknowledge and pay special attention to issues that may be trauma-related. Patients or clients impacted by trauma may be easily triggered, so a supportive environment is critical. A trauma-informed professional may be able to conduct appropriate screening to evaluate potential clients and determine whether trauma is likely to play a role in the etiology of what is presenting whether it is medical, mental health, or substance use disorder related.

With this being said, trauma is often the missing piece of the puzzle. In my practice, when I receive a call about a new client who has complex issues (medical, mental health, substance use disorder, or any combination), the first question I usually ask is whether there has been any history of childhood trauma. I often have to ask the question several ways because what may not seem traumatic to one person may have been very traumatic to another person. We each experience things very differently depending on what we have been through before, how resilient we are, and other factors that may not even be in our active memory, especially if they happened while we were still embryos! I want to highlight that trauma does not have to be limited to childhood. As mentioned above, COVID-19 has been a source of trauma for many. Natural disasters such as wildfires and hurricanes, riot and gang-related incidents, bad drug-related experiences, or the loss of a family member can also be traumatic experiences. These can happen at any age. Childhood (which includes embryo through adolescence in this case) is just especially risky because it is a significant developmental period.

If a given experience was incredibly traumatic, our brain often protects us by suppressing that event's memory, which does not mean it has not had a significant impact. A trained mental health professional will help an individual affected by this identify that it happened and work through it safely. Good trauma work will include:

• Identifying the relevant events
• Figuring out appropriate and safe ways to work through them
• Teaching the client coping tools to manage through future triggers and events to avoid and avert future traumas

The most important thing to know is that past trauma will keep getting in the way of other diagnoses and healing that needs to occur. Diagnosis and treatment progress in other areas (those pesky medical, mental health, and substance use issues) are unlikely to be satisfying and long-lasting until trauma work is well underway. But, there are tools to help and professionals who know how to apply them and teach patients how to use them. A topic that is so common and has such depth, like trauma, may trigger unanswered questions. Hopefully, this has increased your awareness of trauma history's importance in considering difficult to treat, complex issues. If you have any questions, as always, HealthACR, LLC is here to help or to direct you to resources that may be able to help if you need them.

Be safe and healthy!

Lee Mulert, MBA, MS, BCPA, CSA

Founder & CEO

lee@healthacr.com